Future anxiety mediates the relationship between organ donation and transplantation knowledge and health-related quality of life

Abstract

BACKGROUND

Knowledge about organ donation and transplantation plays a crucial role in shaping individuals' health behaviors and perceptions, potentially impacting their health-related quality of life (HRQoL). Future anxiety, defined as the anticipatory worry individuals experience regarding potential negative events and outcomes in their future, may further influence these outcomes.

AIM

To investigate the effect of such knowledge on HRQoL and to examine whether future anxiety mediates this relationship.

METHODS

A cross-sectional study was conducted with 659 participants aged 18 to 65 years. Participants completed the Organ Tissue Donation and Transplantation Knowledge Scale, the Dark Future Scale, and the European Health Interview Survey-Quality of Life 8. Correlation analyses were performed, followed by Structural Equation Modeling to test the proposed mediation model.

RESULTS

The findings indicated that greater knowledge about organ donation and transplantation was positively associated with higher HRQoL and negatively associated with future anxiety. Future anxiety was negatively correlated with HRQoL. Structural Equation Modeling analysis indicated that knowledge directly enhanced HRQoL and reduced future anxiety. Additionally, future anxiety negatively affected HRQoL, mediating the relationship between knowledge and HRQoL. The mediation effect was significant, as confirmed by bootstrapping (bootstrap coefficient = 0.068, 95%CI: 0.046-0.093).

CONCLUSION

The study concludes that future anxiety partially mediates the positive impact of knowledge about organ donation and transplantation on HRQoL. These results suggest that increasing public knowledge in this area may reduce future anxieties and enhance quality of life.

Key Words: Health-related quality of life; Organ donation and transplantation; Future anxiety; Structural equation modeling; Mediating

Core Tip: This study explores the link between organ donation and transplantation knowledge and health-related quality of life (HRQoL), with a focus on the mediating role of future anxiety. Findings reveal that increased knowledge is associated with improved HRQoL and reduced future anxiety. Structural Equation Modeling shows that future anxiety partially mediates this relationship, indicating that reducing future anxiety can amplify the positive effects of knowledge on HRQoL. These results highlight the importance of educational interventions to boost public awareness, reduce anxiety, and promote overall well-being.

INTRODUCTION

The level of knowledge about organ donation and transplantation reflects individuals' awareness and understanding of the fundamental workings of these crucial medical procedures, their ethical dimensions, and their impacts on the healthcare system[1]. This knowledge is vital for both donors and potential recipients, directly influencing their decision-making processes. Enhancing awareness of organ donation not only contributes to the overall healthcare system but also increases the survival chances of individuals suffering from organ failure[2]. Furthermore, raising societal awareness and correcting misinformation help foster positive attitudes toward organ donation within the community[3]. In this context, it has been demonstrated that the level of knowledge about organ donation and transplantation affects individuals' health behaviors as well as their decisions that consider societal benefit.

The level of knowledge regarding organ donation and transplantation is considered a significant factor influencing society's health perceptions and individuals' levels of future-related anxiety. Future anxiety, a psychological construct referring to the fear of uncertain and potentially negative future events, has been shown to mediate the relationship between health-related factors and overall well-being[4]. In this regard, the concept of health-related quality of life (HRQoL) refers to the overall quality of life based on health, encompassing individuals' physical, mental, and social well-being[5]. HRQoL pertains not only to the presence or absence of diseases but also to how individuals perceive their daily lives and how health problems affect their quality of life[6].

Having sufficient knowledge about organ donation and transplantation can shape individuals' health behaviors and enhance their perceptions of overall well-being[7]. Research indicates that individuals with higher levels of knowledge are more likely to engage in proactive health behaviors, experience lower levels of future anxiety, and report improved quality of life[8-10]. This knowledge not only deepens the understanding of organ transplantation but also helps individuals prepare for potential health challenges they may face in the future, increasing their trust in healthcare services[11,12]. An elevated level of awareness can reduce health-related anxieties, leading to improvements in stress management and overall quality of life.

When exploring the relationship between knowledge of organ donation and transplantation and health-related quality of life, the concept of future anxiety emerges as a significant mediating variable. Future anxiety is defined as the worry and fear individuals experience regarding potential negative events in an uncertain future[12]. This form of anxiety can affect individuals' current mental states and health perceptions, resulting in noticeable changes in their quality of life[13]. According to cognitive-behavioral theory[14], a higher level of knowledge may help individuals restructure and manage concerns about uncertain medical outcomes, thus reducing future anxiety. Similarly, from a health belief model perspective[15], enhanced understanding of organ donation and transplantation may increase perceived benefits while reducing perceived barriers, thereby improving health-related behaviors and attitudes. Research indicates that individuals with higher levels of knowledge often manage future anxiety more effectively, thereby enhancing their quality of life[16]. It is suggested that being informed about organ donation and transplantation can alleviate concerns about the future, fostering a more positive health perception. For instance, this level of understanding can increase trust in the healthcare system and contribute to a reduction in anxiety about potential health risks[17]. Thus, considering future anxiety as a mediating variable provides a stronger and more direct explanation of the impact of knowledge about organ donation and transplantation on HRQoL.

The present study

Organ donation and transplantation are pivotal in saving lives and improving healthcare outcomes, yet public misconceptions and insufficient knowledge may deter individuals from fully engaging with this life-saving process[18]. By examining how knowledge of organ donation and transplantation affects HRQoL, this study sheds light on strategies that could alleviate societal concerns and bolster trust in healthcare services.

The present study primarily aims to investigate the effect of knowledge about organ donation and transplantation on health-related quality of life. Furthermore, it seeks to clarify how future anxiety-defined as the worry individuals experience about uncertain and potentially negative events[4,10,19]-mediates this relationship. By identifying the mechanisms through which knowledge can reduce future anxiety and thereby enhance HRQoL, the findings aim to contribute novel insights to the literature on health psychology and health promotion. Such insights can help shape interventions and educational programs, offering a more comprehensive approach to improving public health behaviors and outcomes.

Grounded in previous work on organ donation knowledge, future anxiety, and HRQoL, the current research aims to extend these findings by exploring how sufficient information regarding organ donation and transplantation might improve individuals’ HRQoL via a reduction in future anxiety. Through this approach, we hope to develop evidence-based strategies that can positively influence health behaviors and strengthen trust in healthcare systems. The hypotheses are presented below.

H1: Knowledge about organ donation and transplantation will positively predict HRQoL.

H2: Knowledge about organ donation and transplantation will negatively predict future anxiety.

H3: Future anxiety will negatively predict HRQoL.

H4: Future anxiety will mediate the relationship between knowledge about organ donation and transplantation and HRQoL.

MATERIALS AND METHODS

This study employed a cross-sectional research design to examine the relationship between knowledge of organ donation and transplantation and HRQoL, as well as to explore the mediating role of future anxiety.

Participant

The study involved a total of 659 participants, 460 females (69.8%) and 199 males (30.2%). Participants’ ages ranged from 18 to 65 years (mean ± SD = 22.40 ± 7.16). Their heights ranged from 150 cm to 190 cm (mean ± SD = 166.01 ± 7.77), and their weights ranged from 40 kg to 145 kg (mean ± SD = 61.36 ± 12.70). In terms of self-reported economic status, 84 individuals (12.7%) identified as low, 525 individuals (79.7%) as medium, and 50 individuals (7.6%) as high.

Data collection

Organ tissue donation and transplantation knowledge scale: Participants’ knowledge levels regarding organ donation and transplantation were assessed using a previously validated scale developed by Ozturk Emiral et al[20]. This instrument comprises 17 items across two subdimensions. All items are rated on a 3-point scale ("right", "wrong", or "do not know"), with higher scores reflecting a greater level of knowledge. In the present study, the scale demonstrated an acceptable reliability coefficient (α = 0.79).

Dark future scale: Future anxiety was measured using the Dark Future Scale, developed by Yıldırım et al[21]. This unidimensional scale consists of five items, each rated on a 5-point Likert scale (1 = strongly disagree, 6 = strongly agree). Higher scores indicate greater anxiety about uncertain or negative future events. The scale showed acceptable reliability in this study (Cronbach’s α = 0.77).

HRQoL scale (European Health Interview Survey-quality of life 8): Participants’ HRQoL was evaluated using the European Health Interview Survey-quality of life 8, an eight-item unidimensional instrument adapted into Turkish by Eser et al[22]. Items in this scale are also rated on a 5-point Likert scale (1 = very bad, 5 = very good), yielding higher scores for better perceived HRQoL. In the present study, the scale exhibited acceptable reliability (Cronbach’s α = 0.84).

Statistical analysis

We started by performing correlation analyses and descriptive statistics, then moved on to Structural Equation Modeling (SEM). SEM is a comprehensive statistical approach that enables researchers to test complex relationships among both observed and latent variables simultaneously, offering a nuanced perspective on how constructs interrelate[23]. To enhance clarity regarding the analysis procedure, a path diagram illustrating both the measurement model and the final structural model has been provided (Figure 1A and B). Adhering Kline's two-step SEM approach[23], we first evaluated the measurement model to confirm that the observed indicators accurately represented the latent variables and that their interrelationships were valid. Once the measurement model was validated, we tested the proposed structural model.

Figure 1 The structural model. A and B: Path diagram illustrating the measurement model (A) and the final structural model (B); C: Standardized factor loadings for the structural model. n = 659; ^bP < 0.01; ODTK: Organ donation and transplantation knowledge; HRQoL: Health-related quality of life.

To interpret the SEM results, we relied on widely recommended model evaluation guidelines, referring to the goodness-of-fit indices suggested by Hu and Bentler[24], including χ², degrees of freedom, Comparative Fit Index (CFI), Normed Fit Index (NFI), Tucker-Lewis Index (TLI), Standardized Root Mean Square Residual (SRMR), and Root Mean Square Error of Approximation (RMSEA). As a result, the ratio of χ² to degrees of freedom (χ²/df) is often used, with values less than 5 considered acceptable and values less than 3 indicating a good fit. The CFI, NFI, and TLI indices measure incremental fit, comparing the proposed model to a baseline (null) model; values exceeding. Ninety indicates acceptable fit, and values above. Ninety-five suggests excellent fit. The SRMR and RMSEA indices evaluate absolute model fit, with SRMR values below. Eight and RMSEA values below. Eight indicating good fit[24].

Additionally, we employed the bootstrapping method with 10000 resamples to further support the significance of the mediation effect. Bootstrapping is a resampling technique that generates confidence intervals for indirect effects. Mediation is considered significant if the CI do not include zero[25]. This approach enhances the robustness of the findings by avoiding assumptions of normality in the data distribution. The mediation is considered significant when zero is not included within the bootstrap CI.

Ethical approval and participant consent

This study was approved by the Yıldız Technical University Ethics Committee (Ethics Approval No: 20241003353). Informed consent was obtained from all participants prior to their inclusion in the study, and they were involved based on the principle of voluntariness. Participants' identities were kept confidential, and the data collected were processed anonymously.

RESULTS

Table 1 provides the descriptive statistics and Pearson correlation coefficients for organ donation and transplantation knowledge, future anxiety, and health-related quality of life, and irrational happiness. The analysis indicated significant associations among these variables. Organ donation and transplantation knowledge was positively correlated with HRQoL (r = 0.453, P < 0.001). Conversely, organ donation and transplantation knowledge was negatively correlated with future anxiety (r = -0.272, P < 0.001), indicating that greater organ donation and transplantation knowledge is linked to lower levels of future anxiety. Furthermore, HRQoL was also negatively correlated with future anxiety (r = -0.359, P < 0.001).

Table 1 Relationships among variables and descriptive statistics.

Variables	1	2	3
Organ donation and transplantation knowledge	-
Future anxiety	-0.272b	-
Health-related quality of life	0.453b	-0.359b	-
Cronbach alpha	0.79	0.77	0.84
mean	13.93	15.97	26.77
SD	2.72	3.55	4.92

^bP < 0.001.

In order to address potential gender-related influences, gender was included as a control variable, and independent-samples t-tests were performed. Specifically, females (n = 460) and males (n = 199) did not significantly differ in organ donation knowledge-t (657) = 0.72, P = 0.47-with females (mean = 13.88, SD = 2.94) and males (mean = 14.05, SD = 2.18) showing similar mean scores. There was also no significant difference in HRQoL-t (657) = 0.69, P = 0.49-when comparing females (mean = 26.69, SD = 5.05) and males (mean = 26.98, SD = 4.62). However, females (mean = 16.19, SD = 3.61) reported significantly higher future anxiety than males (mean = 15.47, SD = 3.40), t (657) = 2.41, P = 0.016, although the effect size was small. Because gender was controlled in our main analyses, these differences did not substantially alter our overall mediation findings.

Measurement model

The measurement model included three latent constructs -organ donation and transplantation knowledge, future anxiety, and health-related quality of life- represented by a total of nine observed variables. Specifically, there were two observed variables each for organ donation and transplantation knowledge and health-related quality of life, and five for future anxiety. The model exhibited a good fit with the data, as indicated by the following statistics: χ² (24, n = 659) = 91.07, P < 0.001, with a χ²/df ratio of 3.79; GFI = 0.971; NFI = 0.963; CFI = 0.973; TLI = 0.959; RFI = 0.945; SRMR = 0.051; and RMSEA = 0.065. Additionally, factor loadings ranged from 0.464 to 0.967, demonstrating that the observed variables were strong indicators of their respective latent constructs.

Structural model

In our structural model analysis, we explored whether future anxiety mediates the relationship between organ donation and transplantation knowledge and health-related quality of life, while controlling for age, gender, height, and weight. The model demonstrated a good fit to the data: χ² (52, n = 659) = 121.68, P < 0.001; χ²/df = 2.34; GFI = 0.973; NFI = 0.959; CFI = 0.976; TLI = 0.964; RFI = 0.939; SRMR = 0.040; RMSEA = 0.045. The results indicated that organ donation and transplantation knowledge had a direct and positive effect on HRQoL (β = 0.473, P < 0.01). Additionally, organ donation and transplantation knowledge was found to have a direct and negative effect on future anxiety (β = -0.276, P < 0.01), which in turn had a direct and negative effect on HRQoL (β = -0.235, P < 0.01). Bootstrapping analysis with 5000 resamples confirmed that the indirect effect was significant (bootstrap coefficient = 0.065, 95%CI: 0.043-0.091) (Table 2). These findings suggest that future anxiety acts as a mediator between organ donation and transplantation knowledge and health-related quality of life. The path coefficients for this model are illustrated in Figure 1C.

Table 2 Direct and indirect effects from the bootstrapping analysis demonstrating the mediating role of future anxiety.

Direct effect	Coefficient	95%CI
		Lower level	Upper level
ODTK: Future anxiety	-0.276	-0.337	-0.202
ODTK: HRQoL	0.473	0.359	0.562
Future anxiety: HRQoL	-0.235	-0.318	-0.151
Indirect effect
ODTK, Future anxiety: HRQoL	0.065	0.043	0.091

ODTK: Organ donation and transplantation knowledge; HRQoL: Health-related quality of life.

DISCUSSION

The results of this study provide significant insights by examining how individuals' knowledge about organ donation and transplantation affects their future anxiety and health-related quality of life. The findings indicate that having knowledge in this area directly and negatively impacts individuals' future anxiety. Moreover, it was determined that future anxiety has a negative effect on HRQoL and that this anxiety mediates the relationship between knowledge of organ donation and transplantation and HRQoL.

These findings reveal that a higher level of knowledge about organ donation and transplantation significantly reduces individuals' future anxiety. This suggests that being well-informed decreases uncertainties, allowing individuals to feel less anxious about potential risks and challenges they might face in the future. Increased knowledge can help individuals feel more confident in their ability to manage future health risks. Within the framework of Bandura's theory[26] of knowledge and self-efficacy, there is a positive relationship between an individual's level of knowledge and their perception of self-efficacy, which can be a crucial factor in controlling future anxiety levels. Therefore, it can be argued that being knowledgeable about organ donation and transplantation leads individuals to experience less anxiety regarding uncertainties and risks they may encounter in the future. This is consistent with prior research highlighting how health literacy and education programs can reduce generalized health anxieties and empower individuals to take proactive steps toward managing their health[27,28]. However, our findings extend this understanding by showing how domain-specific knowledge, such as organ donation, uniquely influences psychological outcomes. This can be explained by the enhancement of individuals' ability to make informed decisions as their health knowledge increases, thereby reducing their levels of anxiety[17].

Another finding of this study is that future anxiety has a negative impact on health-related quality of life. This result aligns with literature suggesting that excessive anxiety can adversely affect individuals' psychological and physical health. According to the Stress and Coping Model[29], anxiety can negatively influence quality of life by depleting individuals' cognitive and emotional resources. In this context, high levels of anxiety may weaken individuals' health-related decision-making processes, stress management abilities, and overall quality of life[30,31]. The relationship between anxiety and HRQoL is well-documented, yet our study provides a nuanced contribution by identifying future anxiety as a specific mediator in this relationship. This finding underscores the importance of addressing anticipatory stressors in clinical and community settings, particularly for individuals navigating complex health systems. The findings indicate that managing anxiety is important for improving HRQoL, and that increasing one's level of knowledge may play a supportive role in this process. Reducing anxiety can make it more likely for individuals to adopt healthy lifestyle habits and maintain their well-being.

Another significant outcome of this study is the direct positive effect of knowledge about organ donation and transplantation on health-related quality of life. This finding supports the notion that knowledge strengthens individuals' health perceptions and promotes positive health behaviors. According to Social Cognitive Theory[32], individuals' knowledge-based perceptions of self-efficacy positively influence their health beliefs and behaviors. Within this theoretical framework, informed individuals feel more confident in managing their health, which in turn enhances their quality of life. This aligns with studies demonstrating that health education initiatives improve not only behavior but also overall satisfaction with health outcomes[33]. Importantly, our findings emphasize that this effect is not limited to general health knowledge but extends to specific domains like organ donation and transplantation. Thus, the study explains how possessing adequate knowledge about complex medical processes like organ donation and transplantation helps individuals feel secure and improves their overall well-being[34].

Practical implications

These findings have several important implications for public health and clinical practice. First, public health campaigns and educational initiatives should prioritize increasing knowledge about organ donation and transplantation. Providing accessible, accurate, and culturally sensitive information can help reduce uncertainties, alleviate future anxiety, and enhance trust in healthcare systems. Community workshops, media campaigns, and outreach programs can play pivotal roles in fostering awareness and promoting positive attitudes toward organ donation. Second, healthcare providers and mental health professionals can implement stress management programs, cognitive-behavioral therapy, or mindfulness interventions to address future anxiety. These strategies can help individuals better manage stressors, thereby improving their health-related quality of life. Finally, healthcare policymakers should consider integrating education about organ donation into broader health literacy programs, as increased knowledge has a cascading effect on confidence, health behaviors, and overall well-being.

Limitations

This study has several limitations. First, its cross-sectional design restricts our ability to determine causal relationships between variables. As a result, we cannot definitively interpret the effects of knowledge about organ donation and transplantation on future anxiety and HRQoL within a causal framework. Second, the use of self-reported questionnaires for data collection may introduce potential biases, such as social desirability bias and inaccuracies stemming from participants' self-perceptions. Additionally, the demographic characteristics and geographical distribution of the sample may limit the generalizability of the findings. In light of these limitations, future research should consider employing longitudinal designs to more clearly elucidate causal relationships and utilizing larger, more diverse samples to enhance the generalizability of the results.

CONCLUSION

This study has found that future anxiety mediates the relationship between the level of knowledge about organ donation and transplantation and health-related quality of life. This finding suggests that the impact of knowledge on HRQoL may occur indirectly through its effect on individuals' levels of anxiety. The mediating role of future anxiety indicates that increased knowledge can lead to reduced anxiety among individuals, thereby contributing to a higher quality of life. These insights underscore the importance of educational initiatives aimed at enhancing public knowledge about organ donation and transplantation, as such efforts may alleviate future anxieties and improve overall well-being.